Decreasing financial margins in rural hospitals and the potential impact on the quality of care are urgent concerns. Nursing care is directly related to quality, and is a basic essential core service for rural hospitals. The effects of legislative initiatives, service area and hospital characteristics on rural hospital nursing are unknown. The Agency for Healthcare Research and Quality and The Institute of Medicine have identified the rural population as a high priority for research. The overall objective of this proposed study is to evaluate the effects of legislative and market influences on rural nursing structure and patient outcomes. The specific aims are to: 1) Describe the impact of legislative changes and market influences on nursing in rural hospitals of various types; and 2) Examine the relationship between rural hospital nursing and patient outcomes. First, in a survey design, nurse executives (N=331) from rural hospitals for which quality outcomes are available will complete a telephone survey to describe the impact of legislative changes and market influences on nursing in rural hospitals. Second, nurse executive survey responses will be used in a cross-sectional correlational design to examine the impact of legislative changes and market influences on nursing in various types of rural hospitals. Third, a time-series design will be used to model changes over-time in financial margins on Registered Nurse Hours Per Patient Day (RNHPPD) and risk adjusted clinical outcomes [Health Care Utilization Project Quality Indicators (QIs) and Patient Safety Indicators (PSIs)], as well as the impact over time of RNHPPD on risk adjusted clinical outcomes (QIs and PSIs). Americans are faced with the dilemma of how to improve healthcare quality and safety, while creating a less wasteful and more efficient health system. This is an urgent priority for the rural population. This study has immediate significance for rural hospitals and rural hospital nursing through the identification of legislative, service area characteristics, hospital characteristics and nursing factors in rural hospitals that are related to quality of care. Study results will enable subsequent interventions to focus on improvement opportunities in rural hospitals. This project has promising potential to improve quality of care to the rural population using the novel approach of focusing on an understudied area, nursing in rural hospitals.